State of Indiana Refugee Health Program Annual Report 2015

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State of Indiana Refugee Health Program

Annual Report: Federal Fiscal Year 2015

December 2015

THAM HIN REFUGEE CAMP: http://interpares.ca/news/aid-refugees-refugees

http://interpares.ca/news/aid-refugees-refugees






Table of Contents

I. Executive Summary……………………………………………………………………….1

II.

Data and Statistics…………………………………………………………………….…...2

a. Demographic Data …………………………………………………………....…..2

b. Health Screening…………………………………………………………………..6

III. Successes & Challenges…….…………………………………………………….……...12

IV. The Year Ahead…………….……………………………………………….…………...13

V. Glossary…………………………………………………………………………….……14

VI. References………………………………………………………………………………..15



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I.

Executive Summary

The United Nations High Commissioner for Refugees (UNHCR) defines a refugee as a

“ person who, owing to well-founded fear of being persecuted for reasons of race, religion,

nationality, membership of a particular social group or political opinion, is outside the country of

his nationality and is unable or, owing to such fear, is unwilling to avail himself of the protection

of that country, or who, not having a nationality and being outside the country of his former

habitual residence as a result of such events is unable or, owing to such fear, is unwilling to

return to it.” Each year, these refugees fleeing persecution and war in their home country are

resettled throughout the United States, including within Indiana. In Indiana, the overwhelming

majority of refugees are from Myanmar (Burma), with other refugees arriving from the

Democratic Republic of Congo, Somalia, Iraq and elsewhere.

Before being granted the status of refugee, individuals receive comprehensive background checks while in UNHCR custody, which may occur while the individual or family is

living in a refugee camp or within a temporary country of refuge. Once they are granted the

status of refugee, they are resettled in the U.S. as legal aliens by non-profit voluntary agencies

that receive their funding from the federal government and private donors. In addition to the

criminal background checks and overall screening process, all refugees receive multiple health

screenings. Guidelines for these health screenings are established by the Office of Refugee

Resettlement (ORR) and include screening for infectious diseases, chronic diseases and mental

health. Refugees first receive a health screening before they travel to the U.S. from a registered

panel physician in their temporary country of refuge. In addition, they receive a domestic health

screening in the U.S. within 30 to 90 days of arrival.

The Refugee Health Program at the Indiana State Department of Health (ISDH) is

responsible for providing oversight and coordination of health services to refugees in Indiana.

The mission of the Refugee Health Program is to support the resettlement of refugees by

providing access and resources for an initial health screening upon arrival to the United States,

by identifying emerging health issues in refugee populations and to provide ongoing support

through relationships with community, state and federal partners.

The ISDH Refugee Health Program has made significant progress, including reaching the

milestone of 100 percent of refugees receiving screening within 30 days of arrival during the lastquarter of 2015 and the expansion of screening services to include newborn, tobacco and mental

health screening. However, new challenges such as diabetes, cancer and high blood pressure are

looming on the horizon for the next refugee generations.



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II. Data and Statistics

The following data is compiled from the Immigrant, TB, and All Refugee Application

(ITARA), the online database used by the ISDH Refugee Health Program. ITARA is a

centralized data collection system used by both ISDH and local refugee screening programs to

collect information on all arrivals to Indiana, including demographic and health screening data.

Unless otherwise indicated, the term “refugee” hereby refers to all arrivals served by the ISDH

Refugee Health Program, which includes primary refugees, secondary refugees, asylees, victim

of human trafficking, parolees and special immigrant visa holders. All data shown is for the

federal fiscal year 2015 (FFY 2015), which includes all refugees who arrived between October 1,

2014 and September 30, 2015.

a. Demographic Data

There were 1,885 refugee arrivals to the State of Indiana in FFY 2015, a 16.9 percent

increase over FFY 2014. According to the U.S. State Department, Indiana is projected to receive1,685 primary refugee arrivals during FFY 2016.

Figure 1.

There has been anoverall 63.1 %

increase in refugee

arrivals to Indiana

in the last four

years.



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Several types of refugee arrivals are eligible for resettlement in Indiana and receive

refugee benefits and health screening. Primary refugees are refugees assigned to come directly

to an Indiana jurisdiction by the U.S. State Department, whereas secondary refugees are assigned

to another state upon arrival and then they decide to come to an Indiana jurisdiction. Asylees are

individuals who travel to the United States individually under a non-refugee status and then

apply for asylum once they have arrived.

Figure 2.

94.0%

4.2%0.7%

0.6% 0.5%

0.1%0.1%

Refugee Arrivals by Arrival Status

Indiana, FFY 2015

Primary Refugee

Secondary Refugee

Asylee

Special Immigrant

Visa

Parolee

Secondary Parolee

Victim of Trafficking

N= 1,885

In FFY 2015, 94%

of refugee arrivals

were primary

refugees.



4

In FFY 2015, refugees from 28 nations arrived in Indiana. The top country of origin was

Burma/Myanmar, comprising more than 80 percent of all arrivals. Table 1 shows FFY 2015

arrivals by CDC regions.

Table 1.

Primary refugees are resettled in either Allen County or Marion County, with Marion

County taking the majority of arrivals. Other refugees, such as asylees and secondary refugees,

can settle in any county within Indiana but receive their health screening in either Allen County

or Marion County.

Figure 3.

SOUTHEAST ASIA 1547

CENTRAL AFRICA 182

MIDDLE EAST 71

EAST AFRICA 44

INDIAN SUBCONTINENT 15

CARIBBEAN 11

NORTH AFRICA 5

MEXICO and CENTRAL AMERICA 4

EAST ASIA 2

EASTERN EUROPE and N.I.S. 2

Unknown 2

Total 1885

Refugee Arrivals by Country Of Origin

Region, Indiana, FFY 2015

80.4% of FFY 2015

arrivals in Indiana

resettled in Marion

County.



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The majority of refugee arrivals in FFY 2015 were between 25 and 44 years old upon

arrival in Indiana. It is also worth noting that more than half of all arrivals were children and

young adults, which due to their age may have different health concerns and risk factors than

adult arrivals.

Figure 4.

Figure 5.

In FFY 2015, 38.6% of

arrivals were between

25 and 44 years old

upon arrival.

In FFY 2015, 53.6% of

refugee arrivals in

Indiana were male.



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b. Health Screening

Refugees, regardless of whether they have lived in refugee camps, often have been exposed

to dire living conditions, including poor sanitation, insufficient or unhealthy food and lack of

access to clean, running water. While sanitation and malnutrition are common health threatsrefugees may be exposed to, they are not the only conditions they face. Refugees can suffer from

varying physical and emotional illnesses, some of which can affect them for life. In order to help

address these possible health issues, refugees receive two health screenings, one before entering

the United States and one 30 to 90 days within arrival in Indiana (ORR, 2012). The ISDH

Refugee Health Program is responsible for ensuring the domestic health screening of refugees

entering the State of Indiana. The results of these health screenings are collected in a database so

that the results can be monitored and used to identify ongoing health issues.

After an individual undergoes the application process and becomes a registered refugee, a

U.S. Overseas Processing Entity (OPE), a federal agency in collaboration with the UNHCR, provides the overseas health screening for all refugees (ORR, n.d.). If a refugee is found to have

health issues that could pose a threat to the public, such as active tuberculosis, then the refugee

will not be permitted to enter the U.S. until the issue is resolved. Documentation of this overseas

health screening is sent with the refugee to the U.S. so the domestic health screening will have a

baseline.

Like the overseas health screening, the domestic health screening is intended to protect the

American people from illnesses that could pose a threat to the public. This domestic health

screening is also designed to ensure refugees are linked to health care in the U.S. and are able to

join the workforce in order to be self-sufficient and be less of a burden on U.S. government

assistance programs. Although it does not screen for specific chronic disease, it does include

measures such as Body Mass Index (BMI) and blood pressure that may indicate a need for a

referral for further evaluation.

Prior to their initial health screening in the U.S., refugees apply for health coverage

through Medicaid. If they are not eligible for traditional Medicaid, they receive benefits through

the Refugee Medical Assistance (RMA) program. The RMA is a federal fund used to assist

refugees in covering the cost of medical care during the first eight months of their transition.

After the initial eight-month period, refugees can apply for the Healthy Indiana Plan (HIP 2.0) orget coverage through other means, such as an employer.



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Figure 6.

Table 2.

Primary Care 1263

Dental 1101

Optometry 189

Pediatrics 113

OBGYN 75

Hearing 38

Mental Health 29

Other 29

ENT 10

Dermatology 8

GI 5

Neurology 4

Urology 3

PHN 1

Family Planning 1

Family Practice 1

WIC 1

Number of Refugee Arrivals Referred by Referral Type

Indiana, FFY 2015

Increased efforts

by the ISDH

Refugee Health

Program and local

health departments

have more than

doubled the

number of refugees

screened within 30

days since 2012.

The most common referral

for refugees in FFY 2015

was for primary care,

followed by dental andoptometry.

During the domestic health

screening, refugees are

referred for further healthservices for any specific

health issues and to ensure

linkage to continued health

care.



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Intestinal parasites are a concern in the refugee population and are part of the domestic

medical evaluation. Refugees arriving from Thailand and Malaysia are given presumptive

treatment overseas and therefore are excluded from screening upon arrival to the U.S. Refugeeswho screen positive for intestinal parasites during their evaluation are offered treatment and

education on how to prevent further infection.

Figure 7.

Refugees who have identified risk-factors for sexually transmitted infections are screened

for gonorrhea, chlamydia and syphilis during their domestic health screening and are offeredtreatment and education if diagnosed with any infection. During FFY 2015, only 2 percent of

refugees screened for syphilis were found to be infected, and no refugee was found to be infected

with gonorrhea or chlamydia.

Since FFY 2012,

there has been a

160% increase in

the proportion of

screened refugees

that test positivefor intestinal

parasites.



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Although refugees found to have active tuberculosis (TB) on their overseas health

screening are not permitted to enter the U.S. until they are treated and no longer infectious, all

refugees are still screened for tuberculosis infection and disease during their domestic healthscreening. Refugees found to have latent TB infection are not infectious and cannot spread TB

infection to others (CDC, 2014) and are offered treatment at no cost to them.

Figure 8.

Since January 4, 2010, HIV status is no longer considered grounds to prevent refugee

entry into the U.S. and may even be used as a reason to be granted asylum status (USCIS, 2009).

Figure 9.

26.9% of

refugees were

diagnosed with

LTBI in FFY

2015. Less than

1% were

diagnosed withactive TB disease.

Among screened

refugee arrivals in

FFY 2015, 1.1%

were HIV

positive.



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Figure 10.

Figure 11.

In FFY 2015,

39.4% of adult

refugee arrivalswith BMI

measured were

considered

overweight.

Although this

proportion

remains lower

than the overall

U.S. population, it

is a noted issue.

In FFY 2015,21.2% of adult

refugee arrivals

with blood

pressure readings

had high blood

pressure (Systolic

≥ 130)



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Refugee children living in camps or poor housing overseas are at high risk for lead

poisoning. Although they are not screened during the overseas health screening, CDC requires

all refugee children age 6 months to 16 years to be screened for lead poisoning during theirdomestic health screening. According to a CDC study, refugees tend to live in older housing

structures upon resettlement in the U.S., so CDC also recommends that refugee children age 6

months to 6 years be retested for lead poisoning after three months of resettlement. The localhealth departments currently are not providing this second screening, since this falls beyond the90 day initial screening period.

Figure 12.

Table 3.

Refugee Arrivals by Pregnancy Status

Indiana, FFY 2015

Total Female Arrivals ≥ 16 Years Old 557

Pregnant 29

Not Pregnant 382

Not Tested 146

Among refugeearrivals under age

17, 10.6% had

elevated blood

lead levels ≥ 5

µg/dl.

Per ORR

guidelines,

screening for

female refugees

age 16 and olderincludes

pregnancy testing

with an opt-out

approach



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III. Successes & Challenges

Since the ISDH Refugee Health Program began in Indiana, refugees were entitled to receive

traditional Indiana Medicaid upon arrival to provide access to medical services. Following

changes to Indiana Medicaid, newly arrived refugees in FFY 2015 between 19 and 64 years old

in Indiana were assigned to the new Indiana health insurance: Healthy Indiana Plan (HIP). HIP

does not provide the same services as traditional Medicaid, including transportation and

interpretation, which are very important components of healthcare access for refugees. In

addition to the limited services, HIP requires monthly monetary contributions to a health saving

account or the payment of co-pays in order to receive services. This change in health insurance

negatively impacted access to domestic health screening and thus screening rates for the first half

of 2015, along with resettlement agencies’ overall ability to serve refugees.

In response, the ISDH Refugee Program worked collaboratively with other refugee

stakeholders to advocate for refugees’ access to traditional Medicaid. In June, the Family andSocial Services Administration granted access to traditional Medicaid for eight months for

refugees. This eight-month period is sufficient for refugees to have their initial health screening

and receive follow-up for any referrals. The eight-month Medicaid coverage has also boosted the

initial health screening rate to 100 percent for the months of July and August and 98 percent in

the month of September. The slight decrease in September was due to an influx of refugees in

that particular month that placed a higher burden on screening resources.

In an effort to provide extensive services to refugees per ORR State Letter #12-09, the ISDH

Refugee Health Program has initiated and implemented several new services to refugees. Mental

health screening is now provided to all refugees age 14 years and older using the Refugee Health

Screener-15 (RHS-15). This screening tool is not diagnostic but allows the screening clinic to

determine which refugees may be at higher risk for mental health issues and need referral for

further services. Newborn Screening (NBS), provided to U.S.-born babies at the hospital, is now

also provided to all refugee children resettled in Indiana age 12 months and under at time of

arrival. The goals of providing this service include diagnosing inherited diseases as well as

reducing infant mortality. The NBS brochures will be translated into refugees’ native languages

for further education to families. Additionally, tobacco screening and education for tobacco

cessation are now provided to refugees age 12 years and older at the time of U.S. arrival. This

tobacco screening, as well as the NBS, are in line with Governor Pence’s road map.

With limited English proficiency, refugees are vulnerable in case of natural or manmade

disasters. Therefore, the ISDH Refugee Health Program has developed an emergency

preparedness brochure for refugees that will be translated into refugees’ native languages and

distributed during cultural orientation at resettlement agencies. In addition, refugees will be



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added as an “At-Risk Population” in the Indiana Emergency Preparedness Planning for local

health departments.

With continued turmoil around the world and the refugee crisis ongoing overseas, there will

continue to be an increasing number of refugees. In 2007, Indiana had approximately 200

refugees per year. Now, more than 1,800 refugees resettled in Indiana during FFY2015. This

increasing number of refugees in Indiana requires not only additional resources but additional

programmatic planning and management to ensure service for refugees and communities of

resettlement and will be an ongoing challenge for the ISDH Refugee Health Program and other

refugee stakeholders.

ISDH Refugee Health Program will continue to oversee the Refugee Health Promotion grant

to assist refugees in navigating the U.S. healthcare system and to educate refugees on health

issues they might face in the U.S.

IV. The Year Ahead

The ISDH Refugee Health Program envisions to:

continue efforts to sustain higher screening rates

continue to screen all refugees for mental health, regardless of signs and symptoms

continue to screen refugee children 0 to 12 months for inherited diseases (NBS)

continue to screen refugees for tobacco use

advocate for Indiana refugee Medicaid to cover interpretation services

screen for specific chronic diseases such as diabetes, high blood pressure and others

integrate refugees’ mental health with other chronic diseases by linking them to other

specialty care, as research shows that people with mental health suffer from chronic

diseases more than the general population

update ITARA to improve data quality and user experience



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V. Glossary

Asylees: Are individuals who, on their own, travel to the United States and subsequently apply

for/receive a grant of asylum. Asylees do not enter the United States as refugees. They may enteras students, tourists, businessmen or even on undocumented status. Once in the U.S., or at a land

border or port of entry, they apply to the Department of Homeland Security (DHS) for asylum.To qualify for asylum status, the person must meet the definition of a refugee and meet an

application deadline. Asylum status permits the person to remain in the United States.

Individuals granted asylum are eligible for ORR assistance and services. (Note that asylum

applicants are not eligible for ORR assistance and services. The only exception is for certain

Cubans and Haitians (ORR, 2015).

Cuban and Haitian entrants are defined as:

A. Any individual granted parole status by the Department of Homeland Security (DHS) as a

Cuban/Haitian Entrant (Status Pending) or granted any other special status subsequently

established under the immigration laws for nationals of Cuba or Haiti, regardless of the status ofthe individual at the time assistance or services are provided, and

B. Any other national of Cuba or Haiti1. Who :(i) was paroled into the United States and has not acquired any other status under the

INA;(ii) is the subject of exclusion or deportation proceedings under the Immigration and

Nationality Act (INA); or (iii) has an application for asylum pending with DHS; and2. With respect to whom a final, non-appealable and legally enforceable order of deportation or

exclusion has not been entered [45 CFR § 401.2]. Cuban and Haitian entrants, along with Cubans

in certain other categories, are eligible to apply for adjustment of status after one year in the U.S.

Parolee: A parolee is an alien who is allowed into the U.S. even though they appear to beinadmissible to the Border and Customs Patrol Officer. Entry will only be permitted for urgent

humanitarian reasons or when the alien’s entry is determined to be for significant public benefit.

The parole is only temporary and the parolee must leave the U.S. when the condition that

allowed them entry ceases to exist.

Primary refugee: A refugee initially resettled in an Indiana jurisdiction (MDH, 2015).

Secondary refugee: A refugee originally resettled in another state in the United States before

moving to Indiana (MDH, 2015).

Special Immigrant Visa (SIV) holders: For their service to the U.S. government in Iraq andAfghanistan, Iraqi and Afghan Special Immigrants (SIVs) are granted status overseas by the U.S.

Department of State and are brought to the United States for resettlement by the U.S. Department

of State. Voluntary agencies and ORR through their programs assist with their resettlement and



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integration into the U.S. An SIV is eligible for ORR benefits and services same as a refugee and

for the same time period as a refugee, from the first day the SIV arrives in the U.S (ORR, 2015).

Victim of human trafficking (VTH):The Trafficking Victims Protection Act of 2000 (TVPA) defines “Severe Forms of Trafficking

in Persons” as:trafficking: the recruitment, harboring, transportation, provision, or obtaining of a personfor the purpose of a commercial sex act, in which a commercial sex act is induced by force, fraud

or coercion, or in which the person forced to perform such an act is under the age of 18 years; or

trafficking: the recruitment, harboring, transportation, provision, or obtaining of a person for labor or services, through the use of force, fraud or coercion for the purpose of

subjection to involuntary servitude, peonage, debt bondage or slavery (ORR, 2015).

Victim of torture:

A. “Torture” means an act committed by a person acting under the color of law specifically

intended to inflict severe physical or mental pain or suffering (other than pain or suffering

incidental to lawful sanctions) upon another person within his custody or physical control;B. “Severe mental pain or suffering” means the prolonged mental harm caused by or resultingfrom:

1) intentional infliction or threatened infliction of severe physical pain or suffering;

2) administration or application, or threatened administration or application, of mind-alteringsubstances or other procedures calculated to disrupt profoundly the senses or the personality;

3) threat of imminent death;

4) threat that another person will imminently be subjected to death, severe physical pain orsuffering, or the administration or application of mind-altering substances or other procedures

calculated to disrupt profoundly the senses or personality.



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VI. References

Office of Refugee Resettlement (2012). Medical Screening Protocol for Newly Arriving

Refugees. Retrieved from http://www.acf.hhs.gov/programs/orr/resource/medical-screening-protocol-for-newly-arriving-refugees

Office of Refugee Resettlement (n.d.) Emotional Wellness and Suicide Prevention. Podcastretrieved from http://www.acf.hhs.gov/programs/orr/programs/refugee-health

Office of Refugee Resettlement (2015). Refugee Fact Sheet. Retrieved from

http://www.acf.hhs.gov/programs/orr/spotlight#fact-sheets Center for Disease Control and Prevention (2014). The Difference Between Latent TB Infection

and TB Disease. Retrieved from

http://www.cdc.gov/tb/publications/factsheets/general/LTBIandActiveTB.htm Minnesota Department of Health (MDH) (2015). Refugee Health Statistics. Retrieved from

http://www.health.state.mn.us/refugee/stats/#primary

United States Citizenship and Immigration Services (2009). Memorandum. Retrieved from

http://www.uscis.gov/sites/default/files/USCIS/New%20Structure/Laws%20and%20Reg

ulations/Memoranda/2009/HIVInadmissibilityFinalHHSRule.pdf

http://www.acf.hhs.gov/programs/orr/programs/refugee-health



http://www.acf.hhs.gov/programs/orr/spotlight#fact-sheets


http://www.cdc.gov/tb/publications/factsheets/general/LTBIandActiveTB.htm




http://www.uscis.gov/sites/default/files/USCIS/New%20Structure/Laws%20and%20Regulations/Memoranda/2009/HIVInadmissibilityFinalHHSRule.pdf









Documents

State of Indiana Refugee Health Program Annual Report 2015